Provider Demographics
NPI:1629962238
Name:CANTRELL, TAMMI L
Entity type:Individual
Prefix:
First Name:TAMMI
Middle Name:L
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 BROCK RD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5232
Mailing Address - Country:US
Mailing Address - Phone:478-697-0899
Mailing Address - Fax:
Practice Address - Street 1:966 BROCK RD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5232
Practice Address - Country:US
Practice Address - Phone:478-697-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN172049363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care